Endometrial Hyperplasia

1. See Also
   1. Endometrial Cancer
   2. Dysfunctional Uterine Bleeding
   3. Anovulatory Bleeding (Metrorrhagia)
2. Associated Conditions
   1. Endometrial Cancer
3. Risk Factors
   1. See Endometrial Cancer Risk Factors
4. Pathophysiology
   1. Unopposed Estrogen causes accumulation of endometrial tissue
5. Associated Conditions: Endometrial Cancer
   1. Simple hyperplasia
      1. Without cellular atypia: 1% risk of progression to Endometrial Cancer if untreated
      2. With cellular atypia: 8% risk of of progression to Endometrial Cancer if untreated
   2. Complex hyperplasia
      1. Without cellular atypia: 3% risk of progression to Endometrial Cancer if untreated
      2. With cellular atypia: 29% risk of of progression to Endometrial Cancer if untreated
6. Precaution
   1. Endometrial Hyperplasia with atypia is associated with co-existing Endometrial Cancer in as many as 42% of cases
7. Signs
   1. See Dysfunctional Uterine Bleeding
8. Differential Diagnosis
   1. See Dysfunctional Uterine Bleeding Causes
9. Diagnosis
   1. See Endometrial Biopsy
10. Evaluation: Indications for Endometrial Cancer Screening
    1. Hereditary nonpolyposis Colorectal Cancer (HNPCC) are at high risk of Endometrial Cancer
       1. Offer annual Endometrial Biopsy starting at age 35 years
    2. Postmenopausal women
       1. Any postmenopausal woman with Vaginal Discharge
       2. Any postmenopausal woman with Vaginal Bleeding (outside of first 6 months on continuous Hormone Replacement)
    3. Menstruating women
       1. Any woman over age 35 years with Anovulatory Bleeding (Metrorrhagia)
       2. Women at any age with refractory Dysfunctional Uterine Bleeding (or prolonged unnopposed Estrogen)
    4. Pap Smear findings requiring further evaluation
       1. All women with Pap Smears showing atypical glandular cells or atypical endometrial cells
       2. All postmenopausal women with Pap Smears showing benign endometrial cells
11. Imaging: Pelvic Ultrasound
    1. Indications
       1. Premenopausal women to identify other causes of Dysfunctional Uterine Bleeding
       2. Postmentopausal women to risk stratify based on endometrial thickness
          1. Endometrial stripe <4 mm is reassuring and does not require additional testing
    2. Contraindications to using pelvic Ultrasound to risk stratify to Endometrial Biopsy or additional testing
       1. Morbid Obesity
       2. Uterine Fibroid tumors
       3. Structural abnormalities of the Uterus
12. Diagnostics
    1. Endometrial Biopsy (first-line)
       1. Indicated as first-line evaluation for women who meet evaluation criteria above
       2. Pelvic Ultrasound may risk stratify postmenopausal women for Endometrial Biopsy if endometrial stripe <4mm and adequate study
    2. Saline Infusion Sonography (Sonohysterography)
       1. Indications as second line study
          1. Focal endometrial lesions
          2. Non-diagnostic Ultrasound
          3. Endometrial Biopsy or persistent symptoms
       2. Contraindications
          1. Endometrial Biopsy or other findings suggests Endometrial Cancer (risk of peritoneal seeding)
       3. Technique
          1. Ultrasound performed after sterile saline infused into Uterus
          2. Allows for better visualization of uterine cavity
          3. Ultrasound-guided biopsy of focal lesions can also be done
    3. Hysteroscopy
       1. Second-line study indicated for diagnosis of Endometrial Cancer where other testing is non-diagnostic
13. Indications: Gynecology Referral
    1. Endometrial Biopsy results
       1. Endometrial Cancer
       2. Endometrial Hyperplasia with atypia
       3. Patients who fail usual sampling
          1. Insufficient sampling
          2. Inconsistency between Endometrial Biopsy and pelvic Ultrasound
    2. Patients who fail conservative therapy
       1. Endometrial Hyperplasia
       2. Perimenopausal Dysfunctional Uterine Bleeding
       3. Anovulatory Dysfunctional Uterine Bleeding
14. Management: Endometrial Hyperplasia with cellular atypia
    1. Fertility preserving measures
       1. Step 1: Complete evaluation by gynecology for co-existing Endometrial Cancer (42% of cases)
       2. Step 2: High dose Progesterone therapy (if no Endometrial Cancer identified)
       3. Step 3: Re-evaluate to confirm Endometrial Hyperplasia effectively treated
       4. Step 4: Periodic surveillance for recurrence of Endometrial Hyperplasia per local consultant recommendations
       5. Step 5: Hysterectomy when child-rearing completed
    2. Postmenopausal or no future fertility desired
       1. Hysterectomy
15. Management: Endometrial Hyperplasia without cellular atypia
    1. Progestin Options
       1. Medroxyprogesterone acetate (Provera) 10 mg orally for 10-14 days per month
       2. Megestrol (Megace) 40 mg orally daily (continuous)
       3. Levonorgestrel-releasing IUD (Mirena)
16. Prevention
    1. Manage Unopposed Estrogen states
17. References
    1. Buchanan (2009) Am Fam Physician 80(10): 1075-88
    2. Sorosky (2008) Obstet Gynecol 111(2 pt 1): 436-47